Failure to Obtain Psychotropic Medication Consent for Gabapentin
Penalty
Summary
The facility failed to obtain a completed and signed psychotropic medication consent form prior to administering a psychotropic medication to a resident. The facility’s psychotropic medication use policy, last revised in July 2022, defined psychotropic medications as those affecting brain activity and included antipsychotics, antidepressants, antianxiety medications, and hypnotics. Record review showed that a resident was admitted with diagnoses including a manic episode, anxiety disorder, and PTSD. Physician orders dated 8/24/25 directed administration of Gabapentin 100 mg by mouth three times daily for anxiety/seizure disorder. Review of the resident’s psychotropic medication consent forms dated 03/12/26 revealed that no consent form for Gabapentin had been completed or was available. During an interview on 03/12/26 at 2:00 p.m., the DON stated that any medication listed as a psychotropic should have a consent form and acknowledged that the resident did not have a consent form completed for Gabapentin use, despite one being required. The DON further stated that the lack of a psychotropic consent form affected resident rights, as residents have the right to know what medications they are receiving and to be informed of potential side effects.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.